Effectiveness of collaborative improvement: evidence from 27 applications in 12 less-developed and middle-income countries.

INTRODUCTION: The improvement collaborative approach has been widely promoted in developed countries as an effective method to spread clinical practices, but little has been published on its effectiveness in developing country settings. Between 1998 and 2008, the United States Agency for International Development funded 54 collaboratives in 14 low- and middle-income countries, adapting the approach to resource-constrained environments. METHODS: The authors analysed data on provider compliance with standards and outcomes from 27 collaboratives in 12 countries that met study inclusion criteria (at least 12 months of data available for analysis and indicators measured as percentages). The dataset, representing 1338 facility-based teams, consisted of 135 time-series charts related to maternal, newborn and child health, HIV/AIDS, family planning, malaria and tuberculosis. An average of 28 months of data was available for each chart. RESULTS: Eighty-seven per cent of these charts achieved performance levels of 80% or higher, and 76% reached at least 90% performance, even though two-thirds had a baseline performance below 50%. Teams achieved average increases of 51.9 percentage points (SE = 28.0) per chart, with baseline value being the main determinant of absolute increase. Teams consistently maintained this level of performance for an average of 13 months (69% of months of observation). The average time to reach 80% performance was 9.2 months (SE 8.5), and to reach 90% performance, 14.4 months (SE = 12.0). CONCLUSION: Collaborative improvement can produce significant, sustained gains in compliance with standards and outcomes in less-developed settings and merits wider application as a strategy for health systems strengthening.

Evidence base for children affected by HIV and AIDS in low prevalence and concentrated epidemic countries: applicability to programming guidance from high prevalence countries.

As global commitment grows to protect and support children affected by HIV and AIDS, questions remain about how best to meet the needs of these children in low prevalence settings and whether information from high prevalence countries can appropriately guide programming in these settings. A 2007 search for the evidence in low prevalence settings on situational challenges of HIV and AIDS-affected children and interventions to address these challenges identified 413 documents. They were reviewed and judged for quality of documentation and scientific rigor. Information was compiled across eight types of challenges (health and health care, nutrition and food security, education, protection, placement, psychosocial development, socioeconomic status, and stigma/discrimination); and also assessed was strength of evidence for situational and intervention findings. Results were compared to three programming principles drawn from research in high prevalence countries: family-centered preventive efforts, treatment, and care; family-focused support to ensure capacity to care for and protect these children; and sustaining economic livelihood of HIV and AIDS-affected households. Findings show that children affected by HIV and AIDS in low prevalence settings face increased vulnerabilities similar to those in high prevalence settings. These findings support seeking and testing programmatic directions for interventions identified in high prevalence settings. However, low prevalence settings/countries are extremely diverse, and the strength of the evidence base among them was mixed (strong, moderate, and weak in study design and documentation), geographically limited, and had insufficient evidence on interventions to draw conclusions about how best to reduce additional vulnerabilities of affected children. Information on family, economic, sociocultural, and political factors within local contexts will be vital in the development of appropriate strategies to mitigate vulnerabilities.

Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case-control study.

OBJECTIVE: To examine the effects of a community-based mutual health organization (MHO) on utilization of priority health services, financial protection of its members and inclusion of the poor and other target groups. METHODS: Four MHOs were established in two districts in Mali. A case-control study was carried out in which household survey data were collected from 817 MHO member households, 787 non-member households in MHO catchment areas, and 676 control households in areas without MHOs. We compiled MHO register data by household for a 22-month period. Outcome measures included utilization of priority services, health expenditures and out-of-pocket payments. Independent variables included individual, household and community demographic, socioeconomic and access characteristics, as determined through a household survey in 2004. FINDINGS: MHO members who were up to date on premium payments (controlling for education, distance to the nearest health facility and other factors) were 1.7 times more likely to get treated for fevers in modern facilities; three times more likely to take children with diarrhoea to a health facility and/or treat them with oral rehydration salts at home; twice as likely to make four or more prenatal visits; and twice as likely, if pregnant or younger than 5 years, to sleep under an insecticide-treated net (P < 0.10 or better in all cases). However, distance was also a significant negative predictor for the utilization of many services, particularly assisted deliveries. Household and individual enrolment in an MHO were not significantly associated with socioeconomic status (with the exception of the highest quintile), and MHOs seemed to provide some financial protection for their members. CONCLUSIONS: MHOs are one mechanism that countries strengthening the supply of primary care can use to increase financial access to - and equity in - priority health services.

Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia.

Health worker motivation reflects the interactions between workers and their work environment. Because of the interactive nature of motivation, local organizational and broader sector policies have the potential to affect motivation of health workers, either positively or negatively, and as such to influence health system performance. Yet little is known about the key determinants and outcomes of motivation in developing and transition countries. This exploratory research, unique in its broader study of a whole range of motivational determinants and outcomes, was conducted in two hospitals in Jordan and two in Georgia. Three complementary approaches to data collection were used: (1) a contextual analysis; (2) a qualitative 360-degree assessment; and (3) a quantitative in-depth analysis focused on the individual determinants and outcomes of the worker's motivational process. A wide range of psychometric scales was used to assess personality differences, perceived contextual factors and motivational outcomes (feelings, thoughts and behaviors) on close to 500 employees in each country. Although Jordan and Georgia have very different cultural and socio-economic environments, the results from these two countries exhibited many similarities among key determinants: self-efficacy, pride, management openness, job properties, and values had significant effects on motivational outcomes in both countries. Where results were divergent, differences between the two countries highlight the importance of local culture on motivational issues, and the need to tailor motivational interventions to the specific issues related to particular professional or other groupings in the workforce. While workers themselves state that financial reward is critical for their work satisfaction, the data suggest a number of non-financial interventions that may be more effective means to improve worker motivation. This research highlights the complexity of worker motivation, and the need for a more comprehensive approach to increasing motivation, satisfaction and performance, and for interventions at both organizational and policy levels.

Health sector reform and public sector health worker motivation: a conceptual framework.

Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc. The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.

Methods for assessing quality of provider performance in developing countries.

OBJECTIVE: To compare the effectiveness of methods for assessing the quality of pediatric outpatient health provider performance in developing countries. DESIGN: Exit interviews, record reviews, and provider interview results were compared with those of direct observation of pediatric patient care. Thirty health care providers in 14 facilities in Lilongwe District, Malawi were interviewed and observed, treating 436 children in August 1994. Caretakers for 426 of the patients were interviewed, and 362 pediatric outpatient entries in the health center patient register were located and reviewed. MAIN MEASURES: Kappa statistics measuring the level of agreement on the same sample were used for three methods (record reviews, provider interviews, and exit interviews) in comparison with the fourth method, direct observation. RESULTS: All three methods had strengths and weaknesses. Exit interviews with caretakers provided reliable responses for many history-taking tasks, easily discernible physical exam tasks, and many counseling tasks. Record review took little time, but provided limited information: however, the results were reliable for treatments. Provider interviews had much lower reliability, but were usable for assessing more rare events (treating severely ill children). CONCLUSIONS: Although exit interviews and direct observation provide the 'best' data, they are most resource-intensive. Depending on the purpose of the assessment, various combinations of methods might be more effective.

A framework for institutionalizing quality assurance.

OBJECTIVE: To develop a framework to support the institutionalization of quality assurance (QA). DESIGN: The framework for institutionalizing QA consists of a model of eight essential elements and a 'roadmap' for the process of institutionalization. The essential elements are the building blocks required for implementing and sustaining QA activities. Core QA activities include defining, measuring and improving quality. The essential elements are grouped under three categories: the internal enabling environment (internal to the organization or system), organizing for quality, and support functions. The enabling environment contains the essential elements of leadership, policy, core values, and resources. Organizing for quality includes the structure for implementing QA. Three essential elements are primarily support functions: capacity building, communication and information, and rewarding quality. The model can be applied at the level of an organization or a system. The paper also describes the process of institutionalizing QA, starting from a state of preawareness, passing through four phases (awareness, experiential, expansion, and consolidation), and culminating in a state of maturity. The process is not linear; an organization may regress, vacillate between phases, or even remain stagnant. Some phases (e.g. awareness and experiential) may occur simultaneously. CONCLUSION: The framework has been introduced in nearly a dozen countries in Latin America and Africa. The conceptual model has been used to support strategic planning and directing Ministry of Health work plans, and also as a resource for determining the elements necessary to strengthen and sustain QA. The next step will be the development and evaluation of an assessment tool to monitor developmental progress in the institutionalization of QA.

Garantia de qualidade dos cuidados de saúde nos países em desenvolvimento / Quality assurance of health care in developing countries

Nos quinze anos desde a Declaração de Alma Ata, na qual a comunidade internacional engajou-se no fornecimento de cuidados primários de saúde (CPS) para todos, foram feitos grandes esforços em quase todos os países em desenvolvimento para a expansão dos CPS. Isto foi alcançado através do incremento dos recursos alocados por fontes nacionais e internacionais, expansão da formação de trabalhadores de saúde e vasta reorganização do sistema de saúde. Foram anunciadas melhorias importantes no alcance e cobertura de saúde pela maior parte de países, muitos dos quais salientaram modestos declínios na mortalidade infantil e algumas reduções em morbilidade especifica. Contudo, as melhorias indicadas não foram sempre comparadas com os recursos utilizados. Além disso, pouco se fez para avaliar a qualidade dos serviços ou para garantir que os recursos tenham um impacto óptimo. Os métodos da Garantia da Qualidade (GQ) podem ajudar aos gestores de programas de saúde na definição de directrizes clínicas e padrões de procedimentos operativos, para avaliar o desempenho comparado com os padrões definidos de desempenho e obter avanços tangíveis na melhoria e eficácia no desempenho do programa. Este monografia fornece uma visado introdutória de GQ para os países em desenvolvimento. Será de interesse para os fazedores da politicas, quadros superiores do Ministério da Saúde (MISAU) e chefes dos serviços de saúde a nível distrital. Será também útil aos Representantes de organizações no sector da saúde, tais como a Agência dos E.U. para o Desenvolvimento Internacional (A.I.D.), a Organização Mundial de Saúde (OMS) e o Fundo de Emergência das Nações Unidas para a Infância (UNICEF)....